Texas Conservative Coalition Research Institute
Comments to the House Committee on Public Health
Response to Request for Information
October 16, 2020
Regarding Charge 3: Review behavioral health capacity in the state, with a focus on suicide prevention efforts and the provision of behavioral health care services to individuals with intellectual and developmental disabilities. Review suicide prevention programs and initiatives across state agencies, evaluate their effectiveness, and identify opportunities for greater coordination. Identify gaps in the continuum of care for individuals with disabilities and challenges for those providing care to them. Additionally, identify any existing administrative and licensing barriers that negatively affect overall behavioral health capacity in the state.
Background
The onset and spread of the coronavirus has highlighted the heroic efforts of frontline healthcare workers who continue to selflessly put their own needs and fears aside to care not only for those with COVID-19, but also their regular patients with broken limbs, cancer, behavioral health issues, and all of the other maladies they fight on a daily basis.
While medical health issues have understandably received much attention over the last seven months, the impact of a prolonged pandemic on mental and behavioral health is now coming to light. For instance, a recent Washington Examiner article found that overdose deaths increased 18% in March 2020 when compared to March 2019; April increased by 29% and May by an astounding 42% over that time one year ago.[i] The most direct cause of these troubling statistics is that shutdowns caused many individuals with substance abuse issues to forego regular treatment, including both daily medication (some that has to be administered by a registered substance abuse provider) and support groups. In addition to this troubling trend, the worldwide changes brought about by the 2020 pandemic are manifesting in other mental health issues as well, such as depression and anxiety caused by heightened stress, isolation, and job losses[ii]- all effects of protracted shutdowns that have yet to be completely realized. One study found that more than half of all adults in the U.S. report “that their mental health has been negatively impacted” by these issues,[iii] and it will likely be years before we are able to fully discern the negative impacts on children of long-term absences from school and social interaction.
Texas’ Provider Shortage
These trying times have underscored a significant healthcare provider shortage in our state. This unfortunately is an issue that we in Texas have experienced for years and is only worsened by current circumstances.
As discussed in TCCRI’s 2019 Health Care & Human Services Task Force Report, over two million Texans live in counties that are served by only 2.5 percent of the state’s physician workforce, with the majority of our counties federally classified as “health professional shortage areas,” or HPSAs. At the time of this writing the Texas Department of State Health Services (DSHS) HPSA map reports that 199 “whole” counties are considered HPSAs, while an additional 14 counties have “partial” designations for lack of access to primary care providers.[iv] That figure is even less optimistic for those in need of mental health services with 206 counties considered “whole” HPSAs for mental health providers and an additional four counties having “partial” designations.
Given these grim statistics, it is little wonder that many Texans can find themselves waiting weeks or months to see a doctor in some areas of the state. With almost 30 percent of Texas doctors over the age of 60, this trend doesn’t appear to be changing anytime in the near future.
It is important to note that while shutdowns related to the pandemic are undoubtedly causing some individuals to experience new mental health issues, they are also impacting individuals with existing mental health issues who may have foregone some care or could be experiencing exacerbated symptoms. All of these factors place additional strain on a provider infrastructure that was already struggling to meet access to care needs across the state before coronavirus.
Increasing Access to Care During COVID-19 and Beyond
While some are quick to offer Medicaid or Medicare coverage expansions, this myopic approach fails to understand the basic premise that coverage does not equal access to care. Even if government programs were expanded to cover every person in Texas, this would not guarantee that everyone could actually be treated.
Understanding these dynamics, Governor Abbott took swift and decisive action to increase access to care. Utilizing emergency declaration authority, the Governor took multiple steps to make it easier for Texans to receive both medical and mental/ behavioral health treatment. These temporary changes included: simplifying the process for out-of-state health care providers in good standing to obtain a Texas license; opening up the pipeline for qualified nursing students to enter the workforce; and easing telehealth and pharmacy regulations. While not all changes made during times of disaster should be made permanent, the past seven months have provided the opportunity for state leaders going into the next session to examine which regulatory requirements are truly necessary to protect health and safety and which are unnecessarily burdensome and could have the unintended consequence of actually hindering Texans from getting the care they need.
Policy Recommendations
The strain on our current health care infrastructure is not going away, even with the downturn of coronavirus cases. With the postponement of less critical medical services and procedures for a few months, and many still likely delaying care, our system will be playing catch-up for the foreseeable future. As state leaders continue to navigate what the 87th Session is going to look like, a critical part of that discussion should focus on comprehensively addressing Texas’ health care provider shortage. While this is broader than behavioral and mental health, these changes will positively impact both behavioral and mental health providers. It should also be noted that in many areas of the state primary care providers, including physicians and nurse practitioners, are often the first line of defense in treating mental health conditions. So, increasing access to all provider groups is essential to meeting Texas’ behavioral and mental health care needs. TCCRI recommends that lawmakers focus on the following areas:
Ensure Appropriate Access to Telemedicine and Telehealth Services:
Though the demand for telemedicine had been increasing prior to the outbreak of COVID-19, mandatory lockdowns in many areas of the country catapulted telehealth visits to the primary method in which providers saw many of their patients for several months. U.S. News and World Report has been tracking the increase in telehealth utilization during the pandemic and found that between March 2019 and March 2020 telehealth claims increased by 4,374% nationally, with about 4.5 million Texans utilizing telehealth over the past several months. The types of claims also evolved from what generally consisted of shorter, post-appointment counseling and follow-up in 2019 to a larger percentage of longer visits in 2020.
The Brookings Institute and John Locke Foundation jointly published a recent report on removing barriers to telemedicine in the age of COVID-19.[v] Although the pandemic certainly informed some of the report’s findings, the suggested reforms would have positive ongoing effects. While there are acknowledged issues such as a lack of broadband access in some areas- a challenge that many in rural Texas are keenly aware of- there are things that state leaders can proactively undertake to increase the use of telehealth and telemedicine services. These issues include:
allowing the practice of telehealth across state lines;
increasing the types of providers and sites that may offer telehealth services;
establishing parameters that discourage opportunities for fraud, waste, and abuse; and
allowing greater innovation for payers to design benefits and coverage utilizing telehealth; and
eliminating or rejecting payment parity mandates between telehealth and face-to-face care.
It should come as no surprise to those who champion free-market principles that the Brookings/ John Locke report found that mandates, including many parity laws, seem to have little impact in driving up anything related to telemedicine except for costs and, in some cases, have a detrimental effect on utilization.[vi] As always, the goal of any legislation aimed at increasing access to, or use of, telehealth should be to reduce burdensome regulations rather than adopt additional mandates.
Though telehealth utilization may decrease some as restrictions on medical visits have lessened, there is no question that this treatment modality is here to stay and will play a larger role in how we interact with our providers on a regular basis post-coronavirus. This has particular promise in Texas where a smart phone or laptop could provide areas of the state with virtual visits to psychiatrists, psychologists, and therapists that they would otherwise not be able to access. And, unlike some other medical specialties, mental health is generally very well suited for telehealth visits.
Ease Regulatory Restrictions for Out of State Providers in Good Standing
Although the practice of certain professions can vary widely from state to state depending on a state’s individual laws, the practice of medicine is not as reliant on regional statutes. The standard of care- or “the informal or formal guidelines that are typically accepted in the medical community for the treatment of a disease or a condition”[vii]- provided by health care professionals is developed by their respective organizations on a national level, such as the American College of Obstetrics and Gynecology, the American Academy of Pediatrics, and the American College of Psychiatrists to name only a few. So, while states may have differing malpractice laws or facility regulations, the best practice guidelines for treating strep throat, delivering a baby, setting a broken arm, or even treating cancer remain the same.
One key to increasing access to care for both in-person and telehealth or telemedicine treatment is easing restrictions for out-of-state providers in good standing to practice in Texas. The Texas Board of Nursing[viii] and the Texas Behavioral Health Executive Council[ix] each take part in interstate compacts that allow eligible registered nurses (RNs), licensed vocational nurses (LVNs), and psychologists to more easily practice within participating states. However, no such programs exist for advanced practice registered nurses (APRNs) or professionals licensed by the Texas Medical Board (TMB).
While Governor Abbott wisely used his emergency authority to fast track licenses for out-of-state providers, this provision will expire with the end of the COVID-19 emergency declaration. Lawmakers in the upcoming session should examine any opportunities to permanently ease this process for out-of-state who are actively licensed and in good standing in their home states. Doing so could not only result in more providers physically within our state, but also in additional providers who are located elsewhere being able to treat Texans via telehealth or telemedicine visits.
[i] Hogberg, David. “Overdose deaths rise, driven by illegal opioids and the pandemic.” The Washington Examiner. October 14, 2020. Available at: https://www.washingtonexaminer.com/news/overdose-deaths-rise-driven-by-illegal-opioids-and-the-pandemic. [ii] Koma, Wyatt, et. al. “One in Four Older Adults Report Anxiety or Depression Amid the COVID-19 Pandemic.” Kaiser Family Foundation.October 7, 2020. Available at: https://www.kff.org/medicare/issue-brief/one-in-four-older-adults-report-anxiety-or-depression-amid-the-covid-19-pandemic/. [iii] Panchal, Nirmita, et. al. “The Implications of COVID-19 for Mental Health and Substance Use.” Kaiser Family Foundation. August 21, 2020. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/. [iv] Texas Department of State Health Services. “Health Professional Shortage Areas: Primary Care.” Available at: https://txdshs.maps.arcgis.com/apps/MapSeries/index.html?appid=49655b85eb5d4cd4b637aafc74467aa4. [v] Lee, Nicol Turner. Karsten, Jack. Roberts, Jordan. “Removing regulatory barriers to telehealth before and after COVID-19.” Brookings and John Locke Foundation. May 2020. Available at: https://www.johnlocke.org/app/uploads/2020/05/Removing-barriers-to-telehealth-before-and-after-COVID-19_PDF.pdf. [vi] Ibid. [vii]Torrey, Trisha. “Understanding Standard of Care for Patients.” Verywellhealth. March 4, 2020. Available at: https://www.verywellhealth.com/standard-of-care-2615208#citation-4. [viii] Texas Board of Nursing. “Nurse Licensure Compact Information.” Available at: https://www.bon.texas.gov/licensure_nurse_licensure_compact.asp. [ix] Texas Behavioral Health Executive Council. “PSYPACT.” Available at: https://www.bhec.texas.gov/texas-state-board-of-examiners-of-psychologists/psypact/index.html.